m Sex: Male

m Age: 33
m Civil Status: Married
m Birth date: May 5, 1977
m Birth place: Bugallon, Pangasinan
m Citizenship: Filipino
m Religious Affiliation: Iglesia ni Cristo
m Highest Educational attainment: Practical Education
m Address: Samat, Bugallon, Pangasinan c/o Metrobank
Magsaysay
m Occupation: Security guard
m Condition on Arrival: WH
m Room No.: 226 bed 2
m Attending Physician: Dr. Revilla/Dr. Ojascastro
m Admitting Physician: Dr. Oliver
m Date and Time of Admission: November 18, 2010 5:00 pm
m |
|





    
m 



Three days PTA, the patient complained of
dizziness after walking a distance of about 100
meters. The dizziness was said to be sudden,
accompanied by nape pain. There was no
associated blurring of vision, nausea, vomiting,
or loss of consciousness. The patient·s condition
was relieved after resting. No medications
were taken or consultations done. However, 1
day PTA the dizziness recurred upon waking up
and now were accompanied by 1 bout of
non-projectile, non bilious vomiting. Frontal
headache and nape pain were also present.
Due to the persistence of his condition,
consultation was then done in this institution
and was subsequently admitted.
m 
 

The patient has no previous history of
hospitalization. He had no history of trauma or
any operation. He has no HPN, DM but has
Gouty Arthritis; last attack was 1 year PTA. He
has no allergy to any food or drug.

m — 


The patient has a family history of HPN and
CVD but no CAD, DM or other heredofamilial
diseases.

m 6





 

The patient is a smoker, consuming 20 sticks
a day for 20 years (20 pack years). He is also an
occasional alcoholic beverage drinker.
m November 18, 2010
m CBC Normal Range
m WBC 12.3 10e9/L «..5-10 10e9/L
m 77.5% N«««««....45-70% N
m 11.1% L««««««..20-40% L
m 4.26% M««««««.0-12% M
m 6.95% E««««««..0-8% E
m 0.274% B««««««0-2% B
m RBC 2.27 10e12/L««4.5-6.00
m MCV 81.1 fl««««...76-96 fl
m MCH 29.2 pg««««.27-32 pg
m MCHC 360g/L«««...320-360 g/L
m IMPRESSION:Mild hypochromic noted
m Elevated WBC which may suggest infection or
underlying inflammatory processes.
m Indications for hemogram or CBC related to red cell
(RBC) parameters of the hemogram include signs,
symptoms, test results, illness, or disease that can be
associated with anemia or other red blood cell
disorder

m Specific indications for CBC with differential count

related to the WBC include signs, symptoms, test
results, illness, or disease associated with leukemia,
infections or inflammatory processes, suspected bone
marrow failure or bone marrow infiltrate, suspected
myeloproliferative, myelodysplastic or
lymphoproliferative disorder, use of drugs that may
cause leukopenia, and immune disorders.
m November 18, 2010
m ‰



m Color: straw
m Reaction: acidic
m Appearance: slightly turbid
m Specific gravity: 1.010
m Pus cells: 1-4/hpf
m RBC: 0-2/hpf
m Mucus threads: occasional
m Epithelial cells: few
m Albumin: positive (+++)
m Sugar: negative
m Crystals: negative
m Casts: negative
m Bacteria: occasional
m Amorphous urates: occasional
m Yeast cells: negative
m Analysis of the urine
affords enormous insight
into the function of the
kidneys.
m Urine test is the medical
procedure conducted
to test urine glucose,
infection of urinary tract,
and to identify presence
of blood cells, protein or
micro organisms in the
Urine. Urine test is one of
the important diagnostic
tests performed to
diagnose urinary tract
infection, and diseases
of urinary tract.
m November 18, 2010 m Arterial blood
m ABG Analysis gas analysis is
m pH 7.346 used to evaluate
7.35-7.45 oxygen and
m PC02 26.3 mmhg
carbon dioxide
35-45 mmhg
gas exchange
m P02 81.6 mmhg
and acid-base
80-100 mmhg
status.
m HC03 14.0 mmol/L m The acid-base
22-26 mmol/L balance of the
m Metabolic acidosis blood is usually
disrupted when
there is a kidney
problem.
m ï m Kidney
m Na 137.2 mmol/L dysfunction
135-148 causes
m K 4.12 mmol/L imbalances in
3.5-5.3
electrolytes,
especially
m Ca 0.85 mmol/L
1.13-1.32
potassium,
phosphorus, and
m Results are within
normal range except calcium. The
for calcium. acid-base
m Hypocalcemia balance of the
blood is usually
disrupted as well.
m ï m
m ALBP 31 g/L...35-41
m Phos 7.89«.3-4.5
m Crea G 12.3«..0.6-1.3
m Urea 20.3«..2.5-6.4
m Too high urea and
creatinine
Blood urea nitrogen
and serum creatinine
are the most
commonly used blood
tests to screen for, and
monitor renal disease.
Creatinine is a product
of normal muscle
breakdown. Urea is
the waste product of
breakdown of protein.
The level of these
substances rises in the
blood as kidney
function worsens.
m Erythrocyte volfr. m Hematology is
m (´PCVµ hematocrit) indicated to
m Male 0.40- determine if there is a
0.54««««..0.234 decrease in
m Female 0.32-0.47 hemoglobin count.
m Hgb massc. m Kidney disease causes
m Male 120-170 low RBCs and
g/L«««..81.5 hemoglobin count
m Female 110-150 g/L which causes anemia.
m Blood/Rh type: ´Oµ RH m It is also used to test
positive compatibility of blood
m Too low hemoglobin for blood transfusion.
‰ 

Both kidneys are small in sizes, more pronounced in
the right with measurement of 84x35x35 mm and
89x40x46 mm respectively with diffuse increase in
parenchymal echogenecity and loss of
corticomedullary differentiation. No evident lithiasis
noted. There is an oval, well defined anechore focus
with posterior sonic enhancement seen at the
interpolar region of the right kidney measuring
11x13x12 mm. Both central sinus echocomplex are
intact.
Urinary bladder: normal urinary bladder distention,
contour and wall thickness. No intraverical lesions nor
shadowy calculiBilateral chronic renal parenchymal
disease

m Renal cortical cyst, right kidney

m Sonographically normal urinary bladder

m Ultrasound is often used in the diagnosis of
kidney disease. An ultrasound is a
noninvasive type of imaging test. In
general, kidneys are shrunken in size in
chronic kidney disease, although they may
be normal or even large in size in cases
caused by adult polycystic kidney disease,
diabetic nephropathy, and amyloidosis.
Ultrasound may also be used to diagnose
the presence of urinary obstruction, kidney
stones and also to assess the blood flow into
the kidneys.
m | 
 
 | |!"
Class: mineral and electrolyte replacement;
supplements
Indication: treatment and prevention of
hypocalcemia
Contraindications: hypercalcemia, renal
calculi, ventricular fibrillation
Use cautiously in: severe respiratory
insufficiency, renal disease, cardiac disease
Adverse reaction: bradycardia, constipation,
nausea, vomiting, calculi, hypercalciuria
Nursing responsibility: Administer calcium
carbonate 1-1.5 hr after meals.
m 6

 
 ï |!"
Class: alkalinizing agents
Indications: management of metabolic acidosis; used to
alkalinize urine and promote excretion of certain drugs in
overdosage situations
Action: acts as an alkalinizing agent by releasing
bicarbonate ions. Following oral administration, releases
bicarbonate which is capable of neutralizing gastric acid.
Contraindications: metabolic and respiratory alkalosis;
hypocalcemia; excessive chloride loss
Adverse reaction: edema, flatulence, gastric distention,
metabolic alkalosis, hypernatremia, hypocalcemia,
hypokalemia, sodium and water retention
Nursing responsibility:
Assess patient for signs of acidosis, alkalosis,
hypernatremia and hypokalemia.
Instruct patient to take medication as directed.
Advise patient not to take milk products concurrently with
this medication. Renal calculi or hypercalcemia may
result.
m Î

Class: ketoanalogs; essential amino acids
Indication: protein energy malnutrition; prevention
and treatment of conditions caused by modified or
insufficient protein metabolism in chronic renal failure
Actions: normalizes metabolic process, promotes
recycling product exchange; reduces ion
concentration of potassium, magnesium, and
phosphate
Contraindications: hypercalcemia, disturbed amino
acid metabolism
Adverse reaction: hypercalcemia may develop
Nursing considerations:
Take drugs as prescribed
Give with food to minimize GI upset
Frequently assess for hypercalcemia
m 



Class: antihypertensives; calcium channel blockers
Indication: management of hypertension, angina pectoris
and vasopastic angina
Action: inhibits the transport of calcium into myocardial
and vascular smooth muscle cells, resulting in inhibition of
excitation-contraction coupling resulting in decreased
frequency and severity of attacks of angina
Contraindications: hypersensitivity, BP < 90 mmhg
Use cautiously in severe hepatic impairment
Adverse reaction: headache, dizziness, fatigue,
bradycardia, hypotension, palpitations, nausea, flushing
Nursing considerations:
Monitor blood pressure and pulse before therapy.
May cause drowsiness or dizziness. Instruct significant
others not to leave the patient alone.
Encourage patient to comply with other interventions for
hypertension. Medication controls but does not cure
hypertension.
m — 
Class: antianemics; iron supplements
Indications: prevention and treatment of irondeficiency anemia
in patients with chronic kidney disease
Action: enters the bloodstream and is transported to the organs
of reticuloendothelial system, where it is separated out and
becomes part of iron stores.
Contraindications: hemochromatosis, hemosiderosis, or other
evidence of iron overload; anemias not due to iron deficiency
Adverse reactions: dizziness, headache, hypotension,
hypertension, tachycardia, nausea, constipation, diarrhea,
epigastric pain, vomiting
Nursing responsibility:
Oral preparations are most effectively absorbed if
administered 1 hr before or 2 hr after meals. If gastric irritation
occurs, administer with meals.
Avoid using antacids, coffee, tea, dairy products with or
within 1 hr after administration of ferrous salts. If calcium
supplementation is needed, calcium carbonate does not
decrease absorption of iron salts if supplements are administered
between meals.
m ï    (per cap contains Paracetamol
325 mg and phenylpropanolamine 25 mg)
Class: cough and cold preparations
Indication: nasal congestion, headache
and fever associated with sinusitis, rhinitis,
common cold and flu
Contraindications: hypersensitivity, coronary
disease, nepropathy
Special precaution: angina, DM, hepatic or
renal impairment, pregnancy
Adverse reaction: headache, dizziness, GI
upset, sweating, thirst, tachycardia,
palpitations, difficulty in micturition, muscle
weakness, tremors, anxiety
1. Decreased cardiac output related to altered
stroke volume secondary to Hypertension
m This is the top prioritized among the actual
problem since his cardiac status falls under the
physiologic needs in Maslow·s Hierarchy of
Needs. It also falls under the circulation in the
ABC principle or the Air, Breathing and
Circulation principle. If there is decreased
blood circulating in the system, essential
elements such as Oxygen and other minerals
will not be transported in every body parts
especially in the essential organs such as brain,
kidney and the like. If there is decreased blood
in this parts, necrosis may occur leading to
organ damage and will eventually cause
death of the patient. This problem should be
addressed to prevent the patient from further
damage.
2. Ineffective tissue perfusion related to
decreased oxygen-carrying capacity of the
blood
m This is the second prioritized among the
actual problem since it falls under the
physiologic needs in Maslow·s Hierarchy of
Needs. It also falls under the circulation in
the ABC principle or the Air, Breathing and
Circulation principle. If there is decreased
oxygen-carrying capacity of the blood,
oxygen will not be transported to different
organs therefore it may lead to organ
damage and may cause the death of the
patient if left untreated. This problem should
be addressed for the patient to carry-out
nursing interventions and activities of the
daily living.
m Resolving these first three problems is
interrelated. Though it is the third
prioritized problem, the fluid volume in
the body is connected with the
circulatory system which is a very
important system in the body. If this
problem is resolved, the risk for cardiac
overload is decreased. Complications
may also be prevented. Complications
like cerebral edema.
m This is prioritized as the fourth problem
since it is an actual problem and that it
can be resolved if the first three are
corrected. Urinary retention can cause
complications and further development
of other diseases he is now experiencing
such as hypertension and non-pitting
edema. Urea that is retained and is a
toxic substance in the body causing his
uremic encephalopathy.
m Activity and exercise is important not
only because it helps in the good
circulation in the body. This can be
resolved if the first two problems are
corrected since oxygen is essential for a
good activity of the muscle and that
nutrients within the blood like calcium.
m Activity and exercise is important not
only because it helps in the good
circulation in the body. This can be
resolved if the first two problems are
corrected since oxygen is essential for a
good activity of the muscle and that
nutrients within the blood like calcium
solving the decrease in muscle strength.
m This can be corrected if the first four
problems are resolved. Urea and the
decrease in oxygen and tissue perfusion
contribute in the disturbed thought
process. Oxygen is needed by the brain
to function well. Since urea is a toxic
substance and that it affects the brain
function. Also, if it increases in the blood,
it can cause sepsis.
m Since there is biochemical dysfunction in
the body that affects the thought
process of the patient, there is a risk for
injury. If the previous problem is
corrected, the risk will be eliminated.
 

 


 


 

A. Decreased cardiac output related ST Dx

to altered stroke volume secondary A After 8 hours of nursing A Monitor vital signs every 2 hours
to hypertension interventions, the patient will A Assess general status
B. Ineffective peripheral tissue a. have a urine output of atleast 200 A Auscultate for heart sounds
perfusion related to decreased cc per shift Tx
hemoglobin concentration in b. verbalize understanding of dietary A Ensure safety by raising side rails
blood and decreased cardiac restrictions A Elevate head of bed to increase
output LT gravitational blood flow
S data A After 3 days of nursing A Provide adequate rest periods
A X k lang naman na ako. Yun lang interventions, the patient will have A Perform assistive range of motion
nanghihina pa rin. Parang pagod a stabilize fluid volume as exercises
ako lagi.´ evidenced by balanced I and , Ed
data stable weight and free of signs of A Instruct to follow the prescribed
A Vital signs taken as follows: edema diet ± low salt and low fat diet
BP=140/100, PR=98, RR=26 A Emphasize importance of smoking
T=36.6 cessation
A Lethargic and restless A Encourage to verbalize needs and
A Confines most of the time in bed concrens
A Pallor noted
A Non-pitting edema noted on the
right foot
A Capillary refill of 3 seconds
A With 2 at 1 lpm per nasal
cannula
 

 


 


 

A. Urinary retention related to ST Dx

B. Excess fluid volume related to
increase reabsorption of water and
sodium secondary to CKD stage V
S data
A XParang lumalaki tiyan ko.´
A XNaiihi ako pero walang
lumalabas. Sumasakit sa bandang
baba ng likod ko pag pinipilit kong
ilabas.´
data
A Abdominal girth of 37.8 inches
A Increase in weight from 64 kg to
67 kg
A Rigid abdomen
A Distended bladder
A Swollen eyes
A Non-pitting edema noted on the
right foor
A Moist mucous membranes
A With patent IFC connected to a
urine bag draining to a yellowish
urine
A S/P: Hemodialysis ± with intact
dressing over the left intrajugular
catheter
A After 8 hours of nursing
interventions, the patient will
a. have a urine output of atleast 200
cc per shift
b. verbalize understanding of dietary
restrictions
LT
A After 3 days of nursing
interventions, the patient will have
a stabilize fluid volume as
evidenced by balanced I and ,
stable weight and free of signs of
edema
A Monitor vital signs
A Monitor intake and output
A Measure abdominal girth
A Assess skin moisture and mucous
membrane
Tx
A Weigh the patient daily
A Restrict sodium intake
A Position in high back rest or semi
fowlers position
A Elevate edematous extremity
A Maintain regulation of IVF to
SKV
Ed
A Emphasize importance of sodium
restriction
A Instruct to report any untoward
signs and symptoms like difficulty
in breathing
A Encourage to verbalize needs and
concerns